The National Surgical Quality Improvement Project (NSQIP) is the best example of an approach to reduce variations in surgical outcomes across hospitals. NSQIP has demonstrated that patient outcomes are significantly improved by comparative assessment of risk-adjusted performance of hospitals against each other, followed by dissemination of the practices of best performing hospitals. The long-term aim of this research, called TQIP - the Trauma Quality Improvement Project, is to improve the quality of care at trauma centers using a NSQIP-like approach. The hypothesis for this research application is that specific, measurable institutional structures and processes of care that contribute to patient outcomes exist at trauma centers and they can be identified. The first specific aim of this study is to identify trauma center structures and processes of care that are associated with their risk-adjusted patient outcomes measured using observed-to-expected patient mortality ratios. These will be derived from previously validated methodologies using an existing nationwide database (National Trauma Data Bank-NTDB). Data on trauma center structures and processes of case will be obtained from the trauma center verification records of ACSCOT, supplemented by a survey of trauma centers. The second specific aim of this study is to calculate the number of lives that may be saved by adoption of modifiable structures and processes of care identified in Aim 1. The third specific aim is to measure the potential impact of improving O/E mortality ratios on trauma center resource utilization (hospital length of stay, intensive care and ventilator use, and costs). This research application is consistent with AHRQ objectives and recent national emphasis on quality of care. The findings will identify targets for improving quality of care at trauma centers, and may form the basis for an evidence-based approach to the trauma center verification process. This research application is submitted in collaboration with the ACSCOT, and is a product of its TQIP quality improvement task force.